Download Laparoscopic Gynae-oncological Procedures: Lessons Learnt After

The Journal of Obstetrics and Gynecology of India (January–February 2014) 64(1):36–40
DOI 10.1007/s13224-013-0446-7
ORIGINAL ARTICLE
Laparoscopic Gynae-oncological Procedures: Lessons Learnt
After a Single Institution Audit of Complications and Their
Management in 567 Consecutive Patients
Puntambekar Shailesh P. • Agrawal Geetanjali A. •
Joshi Saurabh N. • Rayate Neeraj V. • Saravana D. N. B.
Deshmukh Avanish V.
•
Received: 18 September 2010 / Accepted: 27 June 2011 / Published online: 13 August 2013
Ó Federation of Obstetric & Gynecological Societies of India 2013
Abstract
Study Objective To retrospectively evaluate the complications of the laparoscopic pelvic surgeries and to formulate the guidelines to avoid them.
Design Retrospective study (Canadian Classification).
Setting Advanced Laparoscopic Institute.
Patients Nine hundred and seven operated for gynecological malignancies.
Intervention Laparoscopic surgeries.
Measurements and Main Results 567 women suffering
from different pelvic conditions were studied in a period of
60 months. The median age of the patient was 35 (11–80).
Complications occurred in 32 patients (32/567, 5.5 %). The
overall incidence of urinary tract injury in all the advanced
cases at our institute was 2.1 % (12/567). The incidence of
bowel injury at our center was 1.76 %. The incidence of
vascular injury at our institute was 1.76 % (10/567).
Conclusion Laparoscopic complications are different
than those seen following open surgeries. Anticipation,
early recognition, and timely intervention help to reduce
morbidity. Laparoscopic management of complications is
possible. Formulating standard guidelines can help to avoid
many such complications.
Puntambekar S. P. (&) Agrawal G. A. Joshi S. N. Rayate N. V. Saravana D. N. B. Deshmukh A. V.
The Galaxy Care Laparoscopic Institute, A Center of Excellence
for Minimally Invasive Oncology, 25-A, Karve Road,
Erandwane, Pune 411004, Maharashtra, India
e-mail: [email protected]
Keywords Complications Laparoscopic surgery Gynaecology
Introduction
Minimal access surgery as a modality for the treatment of
pelvic pathologies is gaining grounds with more and more
gynecological cancers being treated laparoscopically. Formulating standard guidelines can benefit the surgeons and
can help to minimize complications. Many studies have
reported their complications but a few have reported their
management [1, 2].
We have been performing minimally access surgery for
gynecological cancers since 2003 (4). This report is to
evaluate the safety of these procedures with the gaining
experience and numbers. We have tried to analyze our
complications, their nature, causes, and management and
formulate their rules for their prevention. Increasing evidence in minimally access surgery along with advancement
in instrumentation has lead to more and more surgeons
adopting these and advanced surgical procedures. It is
imperative for the surgeons to know the right steps of surgery
and be aware of its likely complications, prevention, and
management. Though several reports have claimed decrease
in the complications with experience, it is in the first few
cases one should try and minimize complications.
In this report we have analyzed our complications. We
have tried to look at their nature and cause and finally have
given some thoughts for future prevention.
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The Journal of Obstetrics and Gynecology of India (January–February 2014) 64(1):36–40
Laparoscopic Gynae-oncological Procedures
Materials and Methods
This is a retrospective study of patients who underwent
various laparoscopic pelvic surgeries for malignancy from
July 2005 to June 2009. All surgeries were done by the
chief author and assisted by same surgical team.
Preoperative Preparation
All patients underwent preoperative bowel preparation
with polyethylene glycol dissolved in 1 l of drinking water
a day prior to surgery. A written informed consent was
obtained. A combination of regional and general anesthesia
was used. Patient was placed in modified Lloyd-Davies
position with bolster below the pelvis at the level of
anterior superior iliac spine. Preoperative catheterization
was done in all patients and nasogastric tube was inserted
under anesthesia.
Primary port was inserted by open umbilical tube
technique and pneumoperitoneum was created. In a patient
with previous surgical scar Veress needle was inserted
through Palmer’s point and blind trochar entry was performed. The port position for all pelvic surgeries was the
same as shown in Fig. 1; a 10-mm camera port at the
umbilicus and another 10-mm working port at Mac Burney’s point. 5-mm working port is placed in the para-rectal
region on the right and similarly two 5-mm retracting ports
are placed on the left side. We evaluated all complications
during laparoscopic pelvic surgeries and their management
as shown in Table 1. Complications were classified as
intraoperative and postoperative depending on type of
organ injury. Complications like postoperative pain, wound
infection, and trochar injury were not included in the study
(grade 1 and 2). Only complications requiring operative
intervention were included in our study (grade 3).
Results
567 women suffering from different gynecological malignancies were studied in a period of 60 months. The median
age of the patient was 35 (11–80). Complications occurred
in 32 patients (32/567, 5.5 %). Major complications were
seen during Laparoscopic radical hysterectomy. Among the
32 complications, 20 were recognized intraoperatively and
were treated immediately. Urinary tract injury was the
most common complication seen in 12/567 patients
(2.11 %). 5 patients had bladder injury and 7 had ureteric
injury. 3 bladder injuries were detected intraoperatively
and were repaired with 2–0 vicryl. Indwelling catheter was
removed after 3 weeks. Two injuries were detected in the
postoperative period. One was treated with laparoscopy
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Fig. 1 Standard pelvic port positions
Table 1 Type of procedures
Procedures
Number Complications
Ureteric Bladder Bowel Vascular
injuries injuries injuries injuries
Lap radical
hysterectomy
408
4
4
4
5
Lap bilateral
salphingooophrectomy with
hystrectomy
Lap anterior
exenteration
75
1
1
2
1
55
0
0
1
2
Lap posterior
exenteration
20
2
0
1
1
Total pelvic
exenteration
09
0
0
2
1
and other required formal repair of vesico-vaginal fistula
by laparotomy after 6 weeks. In the patients with suspected
ureteric injuries, D J stenting was attempted successfully in
three patients. In patients where the stenting could not be
done laparoscopic reimplantation was done. Vascular
injury was seen in 10 patients (1.76 %) undergoing major
surgery laparoscopically. Out of that 8 injuries were seen
intraoperatively and 2 presented with secondary hemorrhage. All vascular injuries were managed by laparoscopic
suturing of the injured vessel except one patient who had
external iliac vein injury which was repaired by laparotomy. 10/567 (1.76 %) patients had bowel injury. Four
patients had small bowel injury and 6 had large bowel
injury. They were managed by laparoscopic primary
suturing. The various procedures with complications seen
in our study are: see Tables 1 and 2.
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The Journal of Obstetrics and Gynecology of India (January–February 2014) 64(1):36–40
Table 2 List of complications
6
5
4
URINARY TRACT INJURY
3
BOWEL INJURY
VASCULAR INJURY
2
1
0
2005
2006
2007
2008
2009
Complications
Management
Ureteric injuries
Double j ureteric stenting
3
Reimplantation with psoas hitch
4
Bladder injuries
Bowel injuries
Vascular injuries
Primary suturing with Foley catheterization
3
Delayed injury
2
Primary suturing
Small bowel
4
Large bowel
6
Primary stirring intraoperative
8
Secondary hemorrhage
2
Discussion
Minimally invasive surgery has known advantages over open
surgery in terms of faster recovery, less postoperative pain,
and quick return to normal life and day to day activity.
Complications following laparoscopic cancer surgeries are
different from those seen in open surgeries. These are due to
the limited vision, instrumentation failure, and various
energy sources used during laparoscopy. Since the view is
limited and techniques vary, every surgeon should be aware
of the possible consequences and should know how to prevent, recognize, and manage them without delay. As the
complexity of the procedures performed laparoscopically has
grown, so also the spectrum of complications. Laparoscopic
complications always get noticed and amplified. These are
quoted by surgeons opposing laparoscopic oncological procedures. Therefore, we decided to evaluate and audit our own
results in more than 500 consecutive patients. The question
we asked is whether we have reached a stage when we have
the safety profile matching that of open surgeries.
Complications were defined as any deviation from the
normal postoperative course. The complications were classified according to severity in 4 categories [3]. Grade 1
included minor risk events not requiring therapy (with
exceptions of analgesic, antipyretic, antiemetic, and antidiarrheal drugs or drugs required for lower urinary tract
infection). Grade 2 complications were defined as potentially
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Number
life-threatening complications with the need for intervention
or a hospital stay longer than twice the median hospitalization for the same procedure. Grade 2 was divided into 2
subgroups based on the invasiveness of the therapy selected
to treat the complication; grade 2a complications required
medications only and grade 2b required an invasive procedure [1]. Grade 3 complications were defined as complications leading to lasting disability or organ resection, and
finally, a grade 4 complication indicated death of a patient
due to a complication (Clavien system) [2]. We have only
included grade 3 patients in our study.
The rate of complications in various studies ranged from
0.2 to 10.30 %. The great variation in the complications rate
may be due to the complexity of the procedure, surgical
skills, and stage of the presentation of diseases. The total
complication rate in our study has been 5.5 % which is
comparable with international study. Injuries to the urinary
tract were the most common of the complications in the
laparoscopic surgery. The overall incidence of urinary tract
injury in all the advanced cases at our institute was 2.11 %
(12/567). Previous cesarean section was the single most
cause increasing the chances of injury. Bladder injuries were
recognized intraoperatively by the presence of pneumaturia
seen in the urinary drainage bag. Pneumaturia is a term used
when the Foley’s urobag gets filled with CO2 gas. This
happens when the urinary bladder is injured giving way to
the gas under pressure used during laparoscopy. The urinary
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The Journal of Obstetrics and Gynecology of India (January–February 2014) 64(1):36–40
bladder injuries detected intraoperatively were repaired
immediately with vicryl 2–0 interrupted sutures in two
layers. The delayed bladder injury was seen after 1 week
and was presented with vesico-vaginal fistula. The cause of
this delayed bladder injury is usually ischemia due to thermal damage. One of the patients with bladder injury presented with vesico-vaginal fistula. Inspite of all the
precautions, some unsuspected bladder injuries may occur in
difficult cases. Its recognition rather than injury is important.
Hence in difficult cases we fill the bladder with normal
saline and check for any leak. This simple test has helped us
to detect injuries intraoperatively. Bladder injuries can be
prevented by following few basic simple techniques. While
doing any pelvic surgery it is important that the bladder is
catheterized with a Foley’s catheter. One should stay at the
plane below the fat of the bladder. The anterior vaginal wall
is devoid of fat and this principle of dissection prevents
bladder injury. In patients of the previous pelvic surgeries
like LSCS the dissection of the bladder should always start
from the lateral side and then continued in the center as there
are adhesions in the center. A combination of blunt and
sharp dissection helps to separate the bladder.
The ureteric injuries in our series manifested within
7–10 days following injury. The clinical presentation was
vaginal urinary leak. Three patients could be managed by
cystoscopic double J ureteric stenting. In four patients in
whom double J ureteric stenting was not possible, laparoscopic ureteric reimplantation by psoas hitch [4] was done.
The ureteric injuries are due to avascular necrosis and
hence presentation is delayed.
It is our policy to visualize the ureter always at the end
of surgery for peristalsis as well as denudation. A double J
ureteric stents should be inserted in doubtful cases either
preoperatively, or in intraoperative or postoperative period.
Among the ureteric injuries, 5 were seen in the first 200
patients of laparoscopic radical hysterectomy, 2 in the next
hundred, and none in the last hundred. This may be due to
number of factors like shifting from bipolar energy source
to ultrasound. In fact, in the last 150 patients we have
stopped using energy source at the level of ureteric tunnel.
Our changing strategy and continuous audit has helped us
to achieve to this safety in patients.
Bowel injury is one of the most important complications
of laparoscopic surgery. It is potentially life threatening,
especially if the injury is not recognized at the time of
operation. It is also one of the common complications in
minimally invasive surgeries [5], the incidence of bowel
injury at our center was 1.76 % (10/567) [6]. More recently,
Zaki et al. [7] Reported two cases of bowel injury among
1508 patients (incidence 1.3:1000) which was mainly seen
in benign gynecological surgeries like sterilization and
infertility. The incidence of these complications is between
0.62 and 1.60 per thousand laparoscopies [8, 9].
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Laparoscopic Gynae-oncological Procedures
The small bowel injuries were during the adhesiolysis of
previous open or lap surgeries. The injury was more
common in the dilated bowel where it was very densely
adherent to the scar. We never used any energy source for
the adhesiolysis. Monopolar current was never used as this
current is known to travel or cause inadvertent blind injury
which can go unnoticed [7]. Rectal injuries were due to
excessive retraction of the rectum.
Recognition of bowel injury is important as they may be
fatal to the patient if not recognized and treated early.
Majority of the bowel injuries were recognized intraoperatively due to greenish discharge on direct visualization or
feculent smell. Only one patient had a delayed presentation
with pain in abdomen, distention, and bilious vomiting
with persistent high-grade fever. She was treated by
exploratory laparotomy and resection anastomosis of the
segment of the bowel.
All large and small bowel injuries diagnosed on table
were treated immediately by laparoscopic primary suturing
with silk 2–0 interrupted sutures in two layers. Thorough
lavage of the spilled contents was done. An elective drain
was also kept at the end of surgery.
The incidence of vascular injury at our institute was
1.76 % (10/567) which was comparable with reported literature [10, 11]. Most of the vessel injuries were during the
difficult pelvic lymph node dissection. These injuries were
in form of a small end and, therefore, could be sutured
laparoscopically. Only in one patient the external iliac vein
was traumatized and hence conversion to open was needed.
One should be very careful while dissecting near the
vessel. One should use minimum of the diathermy current
near the vessels [12]. Use of blunt dissection instead of
sharp with suction tip at the time of nodal clearance is
advisable. To avoid the injury we recommend that one
should always dissect parallel rather than perpendicular to
all the tubular structures.
Immediate compression of the bleeding vessels is the most
important step as this will help to take further steps correctly.
Free left hand of the surgeon was the key to success in
achieving control of the bleeder. After the bleeder was caught
the vessel was clipped with the vascular clip wherever it was
feasible. Suction was used to identify the exact site of bleeding
and to control it. The bleeding vessel was sutured laparoscopically after identifying the exact site when it was not
possible to control by clip [13]. One patient had external iliac
vein injury and needed laparotomy. The vein was sutured with
4–0 prolene. Patient was discharged uneventfully.
In our series the overall incidence of complications is
comparable to those seen during open oncological procedures.
Majority of the open surgery complications are under-reported
and hence the true incidence is never known, while in laparoscopy all these are evident. Almost all our (90 %) complications were managed laparoscopically and hence the benefit
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Puntambekar et al.
The Journal of Obstetrics and Gynecology of India (January–February 2014) 64(1):36–40
of minimally access was not lost even after a complication. In
the last 150 patients we have no complications with the patient
getting discharged on the third postoperative day.
The vascular, bowel, and bladder injuries did not lead to
increase in the hospitalization; only in patients who needed
ureteric reimplant, the hospital stay was more than 5 days.
Increasing one’s own experience and standardizing the
techniques, good team, and availability of all advanced
instrumentation have lead to zero complication in the last
150 patients. Hence it is imperative to audit once own
experience so as to achieve the steps of 100 % safety.
Conclusion
Complications are integral part of any surgery. While in those
in open are under-reported, those in laparoscopy are obvious.
90 % of the complications can be recognized and repaired at
the time of primary surgery. With gaining one’s own experience, standard steps, and auditing one’s records, we can
achieve 100 % safety profile in gynecological oncosurgery.
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